AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT
ADD
Social Security No.
DELETE
CHANGE
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Semi Monthly
Monthly
Employee Name ____________________________ Telephone # ________________
(PRINT NAME)
I, hereby authorize Tennessee State University to deposit my net pay, and all other non-payroll amounts due to me,
automatically to my account(s) at the financial institution(s)/credit union(s) indicated, and to initiate, if necessary,
debit entries and adjustments for any credit entries made in error, and for the financial institution(s)/credit union(s)
indicated below to credit and/or debit the same to such account(s). I understand this agreement may be terminated
by me upon proper execution of another authorization agreement. I further understand that, in the event I terminate
my employment, my payroll deposits will continue to be made to the above account(s), while all non-payroll deposit
of amounts due will continue to be made until such time as I properly execute another authorization agreement.
THIS FORM REPLACES ANY PRIOR EXISTING AGREEMENTS PREVIOUSLY SUBMITTED.
______________________________________
_______________
Employee Signature
Date
=====================================================================
If you have more than one account, please put the account with the $ amount FIRST.
FINANCIAL INSTITUTION NAME (First Account – Deposit Amount $________ or 100%)
FINANCIAL INSTITUTION (Check must be attached)
ROUTING NUMBER
ACCOUNT NUMBER
________________________________
Signature of Financial Institution Officer
Checking
Savings
______________________________
Title of Financial Institution Officer
FINANCIAL INSTITUTION NAME (Second Account – Deposit Amount $_______ or 100%)
FINANCIAL INSTITUTION (Check must be attached)
ROUTING NUMBER
ACCOUNT NUMBER
________________________________
Signature of Financial Institution Officer
Example
Check
Checking
Savings
______________________________
Title of Financial Institution Officer
Effective Date:_______
HR Acknowledged:_____
Employee Copy:______
Date Processed:______
Routing Number
REV. 9/07
Account Number